住院病历缺陷与潜在性医疗纠纷的调查  

INVESTIGATION ON DEFECTS IN MEDICAL RECORDS(MR)AND POTENTIAL MEDICAL DISPUTES

作　　者：冯家琳[1] 王宇红[1] 高琨[1] 陈文权[1] 魏丽云[1] 林敏[1] 

机构地区：[1]广东汕头大学医学院附属第二医院信息科,汕头515041

出　　处：《现代预防医学》2007年第5期916-918,共3页Modern Preventive Medicine

基　　金：广东省医学科研基金项目(A2005451)

摘　　要：[目的]了解病历书写中存在的主要缺陷并且评估潜在的医疗纠纷风险。[方法]对某医院近5年内各科病历随机抽取20%进行抽样调查,根据《广东省病历书写规范》中7大项目及所包含的92个子项目进行常见病历缺陷统计。[结果]最常见是重要内容缺项(48.79%);其次是缺签名(15.56%),修改病历(包括涂改病历)列为缺陷第3位(11.15%)。[结论]为预防潜在的医疗纠纷,该院应加强病历的三级质控。[ Objective] To observe the main defect items in MR and evaluate the risk of potential medical disputes. [Methods] 20% MR in the hospital in recent 5 years were investigated with random sampling. The contents of investigation concerned about 7 main parts and 92 items according to the guide of MR handwriting, published by Health Department of Guangdong Province. [Results] The commonest defect was the loss of some important items （48,79%） . No signature in MR ranked the second （15.56%）, and the correction of handwriting was the third defect （11.15%） . [Conclusion] To prevent potential medical disputes, the quality control of MR in 3 classes should be enforced in this hospital.

关 键 词：病历 缺陷 医疗纠纷 

分 类 号：R197.323[医药卫生—卫生事业管理]